Sarah Gottlieb 

One shot: design guidelines for single-use medical devices

RCA Communication Art & Design

Research partner
NHS National Patient Safety Agency

Thousands of single-use, small-scale medical devices such as catheters, dressings, syringes and surgical sutures are used in hospitals every day. However the design of their packaging and labelling can often lead to misuse and mis-selection by medical staff, as key information is not immediately visible. This project set out to work towards clearer information design, evaluating existing problems and solving them through design guidance. The study is supported by the National Patient Safety Agency (NPSA), which informs and influences the health sector on safer patient care.

Between April 2006 to March 2007, 24,207 patient safety incidents involving medical devices were reported to the NPSA’s Reporting and Learning System. This equates to 66 adverse incidents every day. The data suggests that such incidents can often be ascribed to human error.

‘Misuse of medical devices is often due to poor labelling’

The research began with an analysis of labelling and packaging in other industries. There is a wealth of existing knowledge that can potentially improve healthcare products and processes. IKEA, for example, has dealt with multi-language manuals by using only image-based instructions. The application of a coherent colour-coding system has been used to good effect in other sectors.

Meetings were held with manufacturers of Single Use Devices (SUDs) in order to understand their design needs, production methods and financial restrictions. User interviews were held with nurses, matrons and procurement personnel. Personal experiences and preferences were noted, along with a discussion of key issues and problems. After a first draft of the design guidelines was completed, creative workshops were held with NHS staff in order to get their feedback. A similar approach engaged designers in the medical packaging industry.

The research resulted in a series of recommendations for SUD packaging design. The use of colour, space and hierarchy of information are just some examples of the many issues highlighted. Each point is illustrated in a book, with accompanying design recommendations.
Interestingly, some of the recommendations have been inspired by the improvised solutions of staff. For example, long and short term catheters are currently only distinguished by a reference number. On one ward, the housekeeper made coloured circles on the existing packaging to make this distinction clearer. The design recommendation builds on this workaround.

Visits to other wards revealed handwritten signs on drawers and shelves indicating what device was stored where. This inspired a shelf-label to be supplied by the manufacturers. The label is to match the design of the medical device, so aiding the selection process and quickly indicating if a device is put back on the wrong shelf.

The design recommendations will undergo final review by a wide range of stakeholders before full dissemination to the medical devices industry in the UK and healthcare procurement groups in the NHS. This work, represented in the exhibition by a proof copy of the book plus a research video and exemplar packs, will join a growing body of similar outputs from the NPSA aimed at improving design for patient safety.

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